the basics

1. Presented by
DR OBAIKE ABBA ADAMS

2.  Case presentation
 Introduction
 Advantages of MVA
 Indications
 Contraindications
 MVA equipments
 Precautions
 Procedure
 Complications of MVA
 Conclusion
 References

3.  A 29-year old woman G1P0+0 with a history of
amenorrhea for 3 months and a positive home urine
pregnancy test.
 Presented with PV bleeding or lower abdominal pain of 2/7
duration and intends to continue the pregnancy, though it
was unplanned.
 O/E: Pale, afebrile
 V/E: NVV, cervical os open, smeared with altered blood.
 Results of urgent ultrasonography to assess fetal viability
reveal an intrauterine gestation with a fetal pole but no
cardiac activity.
 Clinical assessment of incomplete miscarriage was made.
 Plan : Manual Vacuum Aspiration after stabilizing.

4.  Manual vacuum aspiration (MVA) is an aseptic
procedure that involves the evacuation of
uterine contents by the use of a hand-held
plastic aspirator.
 Used commonly in both developed and
developing countries.
 Approximately one in four women will
experience a miscarriage in her lifetime.

5. First trimester (≤12Weeks)
1. Medical
– Mifepristone(RU 486)- Antagonist to progesterone
– Mifepristone & Misoprostol
– Misoprostol alone
2. Surgical
– MVA
– EVA
– Dilatation & Curettage (now obsolete)

6.  The World Health Organisation recommends
Manual Vacuum Aspiration for uterine
evacuation because it is:
1. Safe, high-quality, affordable
2. Easy to learn, Easy to use
3. Small, portable, quiet, no electricity
required
4. Ideal for performing procedures in the
outpatient setting.

7. 1. Less pain therefore less need for analgesia
2. Reduced risk of complications-bleeding
3. Less post abortal morbidity
4. Less hospital stay
5. Less time (about 10-15 minutes)

8.  Therapeutic
1. Treatment of incomplete abortion for GA up to
12 weeks
2. First trimester abortion(menstrual regulation)
when indicated.
3. Missed abortion GA ≤ 12weeks
4. Gestational trophoblastic diseases-molar
pregnancy
5. Septic abortion ≤12 weeks GA
6. Inevitable abortion ≤ 12 weeks GA
7. Blighted ovum or anembryonic gestation.

9.  Diagnostic
1. Endometrial biopsy
2. Dysfunctional uterine bleeding
3. Retained product of conception (2o PPH)
4. Confirmatory test for ovulation
5. Molar pregnancy (up to 24 weeks)

10.  ABSOLUTE
1. TOP > 12 weeks GA because, bony tissue
and other body tissue is formed which is
difficult to be evacuated via suction.
 RELATIVE
1. Purulent cervicitis and pelvic infection
2. Coagulation disorders

11. 1. MVA Kit:
◦ Karman syringes (MV aspirator)
◦ Cannulae
2. Instruments:
◦ Vulsellum or Tenacullum
◦ Sponge holding forceps
◦ Kidney dish
◦ Hegar’s dilators
◦ Uterine sound
◦ Cusco or sim’s speculum

12. 3. Drugs used:
◦ 1% Lidocaine (xylocaine)
◦ Diazepam
◦ Pentazocine/Tramadol
◦ Normal saline
◦ Oxytocin
4. Others:
◦ Cotton swabs
◦ Vaginal/perineal pads
◦ Vaginal drapes
◦ Sterile gloves
◦ Syringes(10mls)
◦ Light source

20. 1. Any serious medical conditions such as
shock, haemorrhage, cervical or pelvic
infection, sepsis, as may occur with incomplete
miscarriage be addressed immediately (e.g
Urgent PCV,BGXM ).
2. Uterine aspiration/uterine evacuation is
often an important component of definitive
management in these cases and once the
patient is stabilized, the procedure should not
be delayed.

21. 3. In cases where the woman has a history of a
blood-clotting disorder, the aspirators and
cannulae should be used only with extreme
caution and only in facilities where full
emergency back-up care is available.
4. The procedure may be done with local
anaesthesia or under analgesia with sedation.

22. 1. Explain procedure to patient and obtain a
written or verbal consent.
2. Priming the cervix with agents such as a
prostaglandin (inserted into the vagina or
taken sublingually) around 3 hours prior to
procedure reduces the risk of cervical
trauma and haemorrhage.

23. 1. Privacy should be maintained (screen or
closed room)
2. All the articles are arranged near procedure
site.
3. All the ornaments, finger rings, bangles etc
are removed.
4. Put on all universal protective
devices(apron, boots).
5. Scrub and wear sterile gloves
6. Assemble the aspirator

24.  Goal: reduce pain and anxiety.
 Choice may be based on woman’s individual
needs or presentation.
1. Psychological pain: anxiety, fear,
apprehension
2. Cervical pain due to dilatation
3. Uterine cramping due to manipulation
 TIMING:
 Drug must be most effective at the time of
the procedure
 Administer drugs 30-45 minutes before the
procedure.

25. 
Non Pharmacological
I.
Gentle, respectful interaction and
communication
II.
Verbal support and reassurance
III.
Gentle, smooth operative technique
IV.
Can supplement but not replace
medications

26. 
Pharmacological
I.
Anxiolytics/sedatives relieve anxiety
Diazepam (IM)
II.
Analgesics to relieve pain such as
Ibuprofen, Pentazocine(IV)
III.
local anaesthesia (for paracervical
block)using lidocaine or pethidine.

27.  Ask the woman to empty
her bladder
 Clean adequately and
drape.
 Clean vagina and vulva
 Assist her in lithotomy
position.
 Conduct a bimanual
exam to confirm uterine
size and position
 Insert speculum and
conduct speculum exam
to confirm findings of
clinical assessment

28.  Position the plunger all
the way inside the
cylinder
 Have collar stop in place
with tabs in the cylinder
holes
 Push valve buttons down
and forward until they
lock (1)
 Pull plunger back until
arms snap outward and
catch on cylinder base (2)
 Negative pressure (600-
660mmHg) is created in
the cylinder.

29.  Follow No-Touch
Technique- no instrument
that enters the uterus can
contact contaminated
surfaces, including vaginal
walls, before insertion
through the cervix
 Use antiseptic-soaked
sponge to clean cervical os.
 Start at os and spiral
outward without retracing
areas.
 Continue until os has been
completely covered by
antiseptic

30.  Paracervical block is
recommended when
mechanical dilatation is
required with MVA.
 Using local protocols,
administer paracervical
block (at 2,4,8,10 o’
clock sites) and place
tenaculum.
 Use lowest anaesthetic
dose possible to avoid
toxicity-e.g if using
lidocaine, the lowest
recommended dose is
less than 200mg

31.  Dilatation of the cervix is required to allow a
canula to pass into the uterine cavity, and the
greater the gestation of the pregnancy, the
greater the amount of dilatation required.
 Dilate cervix to allow a cannula approximate
to the GA to fit snugly through the os.
 If cervix is insufficiently dilated, use
mechanical dilators or progressively larger
canulae to dilate.

32.  While applying traction to
tenaculum, sound the
uterus then insert
cannula through the
cervix, just past the os
and into the uterine
cavity until it touches the
fundus, and then
withdraw it slightly.
 Do not insert the cannula
forcefully
 The size of cannula is
roughly the number of
gestational weeks i.e
7wks=7mm cannula

33.  Attach the prepared aspirator
to the cannula if the cannula
and aspirator were not
previously attached
 Release the vacuum by
pressing the buttons
 Evacuate the contents of the
uterus by gently and slowly
rotating the cannula 180o in
each direction, using an in-
and-out motion.
 Re-charge aspirator if
necessary.
 When the procedure is
finished, depress the buttons
and withdraw the instruments.

34. 1. Red or pink foam without tissue is seen
passing through the cannula
2. A gritty sensation is felt as the cannula
passes over the surface of the evacuated
uterus.
3. The uterus contracts around or grips the
cannula.
4. The patient complains of cramping or pain,
indicating that the uterus is contracting.

35.  Empty the contents of
the aspirator into a
container.
 Strain material, float in
water or vinegar and
view with a light from
beneath
 Inspect tissue for the
products of
conception, complete
evacuation and molar
pregnancy.
 Send products for
histology.

36.  STEP 9: Perform any concurrent procedure
 When procedure is complete, proceed with
contraception or other procedures, such as
IUD insertion or cervical tear repair.
 STEP 10: Process Instruments
 Immediately process or discard all
instruments, according to local protocol.

37. 1. Apply perineal pad and ensure that the
woman is resting comfortably
2. Monitor vital signs and blood loss for at
least 2 hours.
3. Pain is moderate and relieved by analgesics.
4. Verify and update tetanus immunization if
unsafe abortion is suspected + Rhogam if
Rh-ve.
5. Run IV Normal saline + Oxytocin(5-10IU) to
help contract uterus.
6. Document your findings for legal purposes.
7. Patient can go home if vitals are stable, if
she can walk and counselled.

38.  Is part of post-abortal care.
 This is the package of care given to women
who have undergone an abortion to prevent
the complications which arises from it.

39. 1. Treatment of any complications.
2. Counselling -to identify and respond to
woman’s emotional and physical health needs.
3. Contraceptive and family planning service to
help her prevent future unwanted pregnancies
or miscarriages.
4. Reproductive and other health services
provided in the facility or referral
5. Community and service provider partnership-
mobilizing resources to ensure timely care.

40.  Warm-baths, compresses for cramping
 Light menstrual-like bleeding or spotting
(few days).
 Next menses:4-8 weeks
 Pregnancy is advised after 2-3 consecutive
normal menstrual cycles.
 Give antibiotics, haematinics and analgesics
before discharge home.
 Advice on hygiene; no vaginal douches

41. 1. Fever, chills, fainting, vomiting.
2. Swollen, tender abdomen.
3. Foul discharge.
4. Bleeding more than normal menses or more
than 2 weeks.
5. Delay in resumption of menstruation(more
than 8 weeks).

42. EARLY LATE
1. Primary haemorrhage
2. Retained products
3. Pelvic infection
4. Uterine perforation
5. Genital tract laceration
6. Incomplete evacuation
7. Air embolism
8. Haematometra
9. Vagal reaction
1. Ashermann’s
syndrome
2. Sepsis
3. Chronic pelvic pain
4. Chronic PID
5. Ectopic pregnancy
6. Infertility

43.  Maternal death is lowest (about 0.6/100000
procedures) in first trimester termination
specially with MVA.

44.  Scheduled before discharge from facility
 Timing varies; usually scheduled within one
week
 May not be at same facility
 Woman may be referred to provider in her
community.

45. 1. High Level Disinfection in 0.5% Chlorine
solution
2. HLD by boiling (abt 20mins)
3. HLD in cidex
4. Sterilization using Autoclave (1210c for
30mins).
5. Sterilization using Etylene oxide(ETO).

46.  Aspirator-discard or replace if:
◦ Cylinder is brittle or cracked or mineral deposits inhibit
plunger movement
◦ Valve parts are cracked, bent or broken
◦ Buttons are broken
◦ Plunger arms do not lock
◦ Aspirator no longer holds a vacuum
 Cannulae-discard or replace if:
◦ Has become brittle
◦ Cracked, twisted or bent, particularly at the aperture.
◦ Cleaning the cannula does not completely remove
tissue.

47.  Early pregnancy failure is a distressing
situation
 The physician needs to be sympathetic to
patients who suffer miscarriage and take
prompt actions when cases that require MVA
present in emergency to mitigate bleeding
and other complications.
 It is important to keep an MVA checklist to
ensure safety and effectiveness of procedure.

48.  Thank You For Listening

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